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Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

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Mar 10, 2015

In October 2013, Scotty Weingart was on the show and suggested that closed chest CPR has no role in traumatic cardiac arrest. It made sense because, after all, the things that cause a traumatic arrest won't be helped by closed chest compressions. Tension pneumothorax, pericardial tamponade, hypovolemia from exsanguination - pushing on the chest isn't going to reverse any of those. But where is the evidence to support that claim? Don't we always compress the chest when the heart has stopped?

There is, unfortunately, a dearth of data on this topic. Swami and I scoured the known literature and here's what we found...

Lockey DJ et al. Development of a simple algorithm to guide the effective management of traumatic cardiac arrest. Resuscitation 2013; 84: 738-42.

The authors' algorithm states that in all traumatic arrests, you should look for a penetrating injury to the chest or epigastrium. If you find one, crack the chest ASAP.

If you don’t see a penetrating injury, consider a medical cause for the arrest.

There are a few key procedures in trauma arrest and the study recommends using the HOT mnemonic.

  • H – Hypovolemia (control external hemorrhage, pelvic binding, long bone splinting and give blood)
  • O – Oxygenation (Airway management)
  • T – Tension PTX (Bilateral decompression and chest tubes)
  • Swami and I add in a second T for tamponade, making it the HOTT mnemonic.

If these three things are addressed and there’s no ROSC, you should consider stopping resuscitation. This simple list emphasizes a systematic approach so that you open the chest when it’s indicated without thinking about it too much.

Leis CC et al. Traumatic Cardiac Arrest: Should Advanced Life Support Be Initiated? Acute Care Surgery 2013; 74: 634-8.

Advanced life support in this article means advanced procedures, not ACLS and CPR. The authors argue that we should resuscitate patients in traumatic arrest stating that 49.1% attain ROSC and 6.6% have a good neurologic outcome, including 23.1% of children.

ALS here included IV fluids, intubation, chest tube insertion, pericardiocentesis and FAST in the field. There was no mention of chest compressions.

Bottom Line: The question as to whether or not closed chest CPR in traumatic cardiac arrest has not been well studied. In the literature we found,  chest compressions were rarely mentioned (if at all). Logistically, compressions can get in the way of life saving procedures and haven't been shown to help (nor have they been shown not to help). Considering the pathophysiology of traumatic arrest, compressions don’t make a lot of sense in the emergency department, since pumping on a closed chest in a patient with no volume (hemorrhagic shock), a hole (pericardial effusion), or obstructed outflow (tension PTX) isn’t going to help.

Links mentioned at the end of the show

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